Maternal mortality remains unacceptably high in developing countries, especially those in which abortion is highly restricted or access to safe abortion or to obstetric and delivery care is poor. Lowering maternal mortality would not only result in better health for women and their children, but would greatly reduce the financial burden on national public health care systems. However, despite the objective set by Millennium Development Goal 5 of a 75% reduction in maternal mortality between 1990 and 2015, many countries have failed tomake substantial progress.
In the lead article, authors Mizanur Rahman and colleagues use data from the Matlab Demographic Surveillance System to compare maternal mortality in the two areas covered by the system. The maternal mortality rate in the Maternal-Child Health–Family Planning Project (MCHFP) area, which receives intensive family planning and maternal and child health services (including safemotherhood care), was 37%lower than the rate in the comparison area, which receives standard government services (35 vs. 56 deaths per 100,000 women of reproductive age) [see article]. This difference in rates resulted largely from the MCH-FP area’s lower pregnancy rate and its lower case-fatality rates for induced abortion, miscarriage and stillbirth. The authors note that interventions to increase contraceptive use; reduce induced abortion, miscarriage and stillbirth; improve the management of such outcomes; and strengthen antenatal care could substantially reduce maternal mortality in Bangladesh and similar countries.
A second article on Bangladesh, by Heidi Bart Johnson and colleagues, compares the economic costs of providing menstrual regulation with those of providing treatment of abortion complications [see article]. In 2008, the incremental costs per case of providing menstrual regulation were 8–13% of the costs of treating severe abortion complications, depending on the level of care. An estimated 263,688 menstrual regulations were provided at public-sector facilities that year, with estimated incremental costs of US $2.2 million; 70,098 women were treated for abortion-related complications in such facilities, with estimated incremental costs of US $1.6 million. According to the authors, increasing access to menstrual regulation would enable more women to obtain much needed care and health system resources to be usedmore efficiently.
Rob Stephenson examines the role of community-level gender equity in shaping men’s likelihood of engaging in risky extramarital sex, defined as having one ormore extramarital partners and not having used a condom at last sex with their regular partner, their casual partners or both [see article]. Using Demographic and Health Survey data from eight African countries, Stephenson found that in five countries, men who lived in communities with more equal ratios of women to men with at least a primary education were less likely to report risky extramarital sex. In four countries, men had lower odds of risky extramarital sex in communities with more equal ratios of women to men who were employed. In three countries, men in communities with greater acceptance of wife-beating or male domination of decision making had elevated odds of risky extramarital sex. The author argues that although HIV prevention programs should work to reduce gender inequities, they also need to recognize the cultural factors that affect men’s sexual behavior by influencing the formation of their masculine identities.
In a review of studies published in English between 1994 and 2009 on the integration of family planning with other health services, Anne Sebert Kuhlmann and colleagues found only nine thatmet their criteria for topic and baseline quality [see article]. Of these, only one met their standards for the highest quality. Seven studies found improvements in family planning–related outcomes, although not all reported the significance of the changes; another found mixed results and one found no effect. The authors conclude that evidence supporting the integration of family planning with other health services remains weak, and that well-designed evaluation research on integration is needed.
Also in This Issue
In a Comment on essential medicines lists, Jane Hutchings and colleagues note that national committees compiling these lists often fail to see reproductive health as a national priority, and that reproductive health drugs and devices are therefore not included [see article]. They point out that poor reproductive health accounts for about one-third of the total burden of disease among women of reproductive age and nearly one-fifth of the disease burden in the general population. Therefore, they argue, providing people with information and access to drugs and devices that allow them to time and space the births of their children, protect themselves against STIs and make childbirth safer for both mothers and newborns needs to be a public health priority.